Level: Foundational
Difficulty: Easy
Subtopic: Renal fluid and electrolyte regulation
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to renal fluid and e…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to renal fluid and electrolyte regulation. Assessment data include the client reports dizziness when standing. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Administer the next scheduled intervention before reassessing the client.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.